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Asset Publisher
Antidepressant Agents Step Therapy and Quantity Limit Program Summary
Policy Number: PH-1101
This program applies to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace formularies.
POLICY REVIEW CYCLE
Effective Date |
Date of Origin |
10-01-2024 |
|
FDA LABELED INDICATIONS AND DOSAGE
Agent(s) |
FDA Indication(s) |
Notes |
Ref# |
Aplenzin® (bupropion extended release) Tablet |
Treatment of: - Major Depressive Disorder (MDD) - Seasonal Affective Disorder (SAFD) |
|
22 |
Auvelity® (dextromethorphan hbr-bupropion hcl tab er) Tablet |
Treatment of Major Depressive Disorder (MDD) in adults |
|
29 |
Celexa® (citalopram)* Tablet Oral solution |
Treatment of depression |
*generic available |
1, 2 |
Citalopram Capsule |
Treatment of Major Depressive Disorder (MDD) in adults |
|
4 |
Cymbalta® (duloxetine delayed release) Capsule* |
Treatment of: - Major Depressive Disorder (MDD) - Generalized Anxiety Disorder (GAD) in adults and pediatric patients 7 years of age and older - Diabetic Peripheral Neuropathic Pain (DPNP) in adults - Fibromyalgia (FM) in adults and pediatric patients 13 years of age and older - Chronic Musculoskeletal Pain (CMP) in adults |
*generic available |
13 |
Desvenlafaxine ER Tablet |
Treatment of Major Depressive Disorder (MDD) |
|
18 |
Drizalma Sprinkle™ (duloxetine DR) Capsule |
Treatment of: -Major Depressive Disorder (MDD) in adults |
|
5 |
Effexor XR® (venlafaxine extended release) Capsule* |
Treatment of: - Major Depressive Disorder (MDD) - Panic Disorder (MDD) - Generalized Anxiety Disorder (GAD) - Social Anxiety Disorder (SAD) |
*generic available |
16 |
Fetzima® (levomilnacipran ER) Capsule |
Treatment of Major Depressive Disorder (MDD) in adults Limitation of Use: Fetzima is not approved for the management of fibromyalgia. The efficacy and safety of Fetzima for the management of fibromyalgia have not been established. |
|
17 |
Fluoxetine 60 mg Tablet* |
Treatment of: - Major Depressive Disorder (MDD) - Obsessive Compulsive Disorder (OCD) - Bulimia Nervosa - Panic Disorder (PD), with or without agoraphobia |
*generic available |
3 |
Fluoxetine Delayed Release Capsule |
Acute and maintenance treatment of Major Depressive Disorder (MDD) |
|
10 |
Prozac® (fluoxetine)* Tablet Capsule Oral solution |
Treatment of: - Acute and maintenance treatment of Major Depressive Disorder (MDD) - Acute and maintenance treatment of Obsessive Compulsive Disorder (OCD) - Acute and maintenance treatment of Bulimia Nervosa - Acute treatment of Panic Disorder (PD), with or without agoraphobia |
*generic available |
11 |
Forfivo XL® (bupropion extended release) Tablet |
Treatment of Major Depressive Disorder (MDD) |
|
23 |
Lexapro® (escitalopram)* Tablet Oral suspension |
Treatment of: - Major Depressive Disorder (MDD) in adults and pediatric patients 12 years of age and older - Generalized Anxiety Disorder (GAD) in adults and pediatric patients 12 years of age and older |
*generic available |
6 |
Paxil® (paroxetine)* Tablet Oral suspension |
Treatment of: - Major Depressive Disorder (MDD) - Obsessive Compulsive Disorder (OCD) - Panic Disorder (PD) - Generalized Anxiety Disorder (GAD) - Social Anxiety Disorder (SAD) - Post-Traumatic Stress Disorder (PTSD) |
*generic available |
7 |
Paxil CR® (paroxetine extended release) Tablet* |
Treatment of: - Major Depressive Disorder (MDD) - Panic Disorder (PD) - Social Anxiety Disorder (SAD) - Premenstrual Dysphoric Disorder (PMDD) |
*generic available |
8 |
Pexeva® (paroxetine mesylate) Tablet |
Treatment of: - Major Depressive Disorder (MDD) - Obsessive Compulsive Disorder (OCD) - Panic Disorder (PD) - Generalized Anxiety Disorder (GAD) |
|
9 |
Pristiq® (desvenlafaxine succinate extended release) Tablet* |
Treatment of Major Depressive Disorder (MDD) |
*generic available |
20 |
Remeron SolTab® (mirtazapine ODT) Orally disintegrating tablet*
|
Treatment of Major Depressive Disorder (MDD) |
*generic available |
25 |
Remeron® (mirtazapine) Tablet* |
Treatment of Major Depressive Disorder (MDD) |
*generic available |
25 |
Sertraline Capsule |
Treatment of: - Major depressive disorder (MDD) in adults - Obsessive-compulsive disorder (OCD) in adults and pediatric patients 6 years and older |
|
24 |
Trintellex® (vortioxetine) Tablet |
Treatment of Major Depressive Disorder (MDD) |
|
27 |
Venlafaxine besylate ER Tablet |
Treatment of: - Major Depressive Disorder (MDD) - Social Anxiety Disorder (SAD) |
|
21 |
Viibryd® (vilazodone) Tablet* |
Treatment of Major Depressive Disorder (MDD) |
*generic available |
28 |
Wellbutrin SR® (bupropion sustained release) Tablet* |
Treatment of Major Depressive Disorder (MDD) |
*generic available |
30 |
Wellbutrin XL® (bupropion extended release) Tablet* |
Treatment of: - Major Depressive Disorder (MDD) - Seasonal Affective Disorder (SAFD) |
*generic available |
31 |
Zoloft® (sertraline)* Tablet Oral concentrate |
Treatment of: - Major Depressive Disorder (MDD) - Obsessive Compulsive Disorder (OCD - Panic disorder (PD) - Post-traumatic stress disorder (PTSD) - Social anxiety disorder (SAD) - Premenstrual dysphoric disorder (PMDD) |
*generic available |
12 |
See package insert for FDA prescribing information: https://dailymed.nlm.nih.gov/dailymed/index.cfm
CLINICAL RATIONALE
Depression |
Selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), bupropion, mirtazapine, and several newer agents are typically used as first-line medications because their safety and tolerability may be preferable to patients and clinicians compared to those of tricyclic antidepressants (TCAs) and monoamine oxidase (MAO) inhibitors(32). Many clinical features and medication characteristics influence the choice of a first-line antidepressant. There are no absolutes, and relative differences between medications are small, hence, selecting an antidepressant involves an individualized needs assessment for each patient(33). No antidepressant has been clearly shown to be superior to another. All FDA-approved antidepressant medications should be considered potentially appropriate for first-line treatment(32). |
Anxiety Disorders |
Guidelines for treatment of anxiety include several anxiety-related conditions: generalized anxiety disorder (GAD), panic disorder (PD), obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and social anxiety disorder (SAD). SSRIs are generally considered first-line therapy for GAD and PD. In the treatment of PD, TCAs are as effective as SSRIs, but adverse effects may limit the use of TCAs in some patients. Extended-release venlafaxine is effective and well tolerated for GAD and PD, whereas duloxetine has been adequately evaluated only for GAD. Due to the typical delay in onset of action, medications should not be considered ineffective until they are titrated to the high end of the dose range and continued for at least four weeks. Once symptoms have improved, medications should be used for 12 months before tapering to limit relapse. Some patients will require longer treatment(34). OCD has a highly selective response to serotonergic medications. SSRIs are preferred for initial therapy. There is insufficient evidence to show that one SSRI is superior, and the choice should be individualized, taking into account potential drug interactions and tolerability. Dosage should be increased over four to six weeks until maximum dose is achieved. Trial of therapy should continue for eight to 12 weeks, with at least four to six weeks at the maximum tolerable dosage. It usually takes at least four to six weeks for patients to note any significant improvement in symptoms; it may take 10 weeks or longer for some. If successful, medication should be continued for at least one to two years, if not indefinitely(35). Among adult patients with PTSD, fluoxetine, paroxetine, sertraline, and venlafaxine are appropriate choices, with none showing improved efficacy over the others(36). For SAD, SSRIs and SNRIs venlafaxine are the clear first-line pharmacotherapy treatment based on demonstrated efficacy in randomized controlled trials and meta-analyses. Medications in these classes that have been FDA-approved in the U.S. are paroxetine (immediate-release and controlled release), sertraline, fluvoxamine controlled release, and venlafaxine extended release. Other medications in these classes with evidence of efficacy from randomized controlled trials include citalopram, escitalopram, and vilazodone. Fluoxetine has had mixed results in randomized controlled trials. SNRIs should be used with caution in patients at risk for suicide due to greater toxicity in overdose. No individual medication within this class has been consistently shown to be superior to another in this class(37). |
Neuropathic Pain |
First-line treatment for neuropathic pain include TCAs, gabapentin, pregabalin, and SNRI antidepressants (duloxetine [most studied], venlafaxine) as first-line therapies(38). For patients with diabetic neuropathy, only two medications, pregabalin and duloxetine, have been approved by the FDA. However, in addition to those two medications, gabapentin and amitriptyline are considered first-line therapy. SNRIs such as venlafaxine and desvenlafaxine are considered second-line therapy. SSRIs such as citalopram, paroxetine, and escitalopram are considered third-line therapy(39). |
Fibromyalgia |
Pharmaceutical therapy recommendations depend on the source of the guideline. Guidelines are available from the European League Against Rheumatism (EULAR-2016), the Canadian Pain Society (2012) and the Association of the Scientific Medical Societies in Germany (AWMF-2012). Recommendations from these guidelines include amitriptyline, pregabalin, gabapentin, SNRIs (including duloxetine and milnacipran), and SSRIs. Amitriptyline, pregabalin, and duloxetine are used most commonly(40). |
Chronic Musculoskeletal Pain |
Antidepressants are options for the treatment of chronic pain. Meta-analyses of randomized controlled trials indicate that TCAs and SNRIs provide effective pain relief for a variety of chronic pain etiologies(41). Duloxetine is FDA approved for chronic musculoskeletal pain(13). |
Safety |
All of the above listed agents have had a black box warning issued by the FDA. The warning concerns suicidal thoughts and behaviors. Since there are small differences between the warnings, they are not listed here. Please see the respective agent’s prescribing information for the warning(1-14,16-18,20-31). |
REFERENCES
Number |
Reference |
1 |
Celexa prescribing information. Allergan USA, Inc. August 2023. |
2 |
Citalopram solution prescribing information. Aurobindo Pharma Limited. August 2023. |
3 |
Fluoxetine 60 mg tablet prescribing information. Nivagen Pharmaceuticals, Inc. June 2021. |
4 |
Citalopram capsule prescribing information. Almatica Pharma, LLC. August 2023. |
5 |
Drizalma Sprinkle prescribing information. Sun Pharmaceutical Industries Limited. July 2021. |
6 |
Lexapro prescribing information. AbbVie, Inc. August 2023. |
7 |
Paxil prescribing information. GlaxoSmithKline. August 2023. |
8 |
Paxil CR prescribing information. Apotex Corp. August 2023. |
9 |
Pexeva prescribing information. Sebela Pharmaceuticals, Inc. August 2023. |
10 |
Fluoxetine delayed release capsule prescribing information. Dr. Reddy’s Laboratories Limited. July 2023. |
11 |
Prozac prescribing information. Eli Lilly and Company. August 2023. |
12 |
Zoloft prescribing information. Pfizer, Inc. August 2023. |
13 |
Cymbalta prescribing information. Eli Lilly and Company. August 2023. |
14 |
Reference No Longer Used |
15 |
Reference No Longer Used |
16 |
Effexor XR prescribing information. Pfizer, Inc. August 2023. |
17 |
Fetzima prescribing information. Allergan USA, Inc. August 2023. |
18 |
Desvenlafaxine ER prescribing information. Alembic Pharms LTC. September 2021. |
19 |
Reference No Longer Used |
20 |
Pristiq prescribing information. Pfizer, Inc. August 2023. |
21 |
Venlafaxine besylate ER tablets prescribing information. Almatica Pharma LLC. March 2022. |
22 |
Aplenzin prescribing information. Valeant Pharmaceuticals North America, LLC. March 2022. |
23 |
Forfivo prescribing information. Almatica Pharma, Inc. December 2019. |
24 |
Sertraline prescribing information. Almatica Pharma LLC. October 2021. |
25 |
Remeron prescribing information. Merck & Co, Inc. November 2021. |
26 |
Remeron SolTab prescribing information. Merck & Co, Inc. November 2021. |
27 |
Trintellix prescribing information. Takeda Pharmaceuticals America, Inc. August 2023. |
28 |
Viibryd prescribing information. Allergan, Inc. August 2023. |
29 |
Auvelity prescribing information. Axsome Therapeutics, Inc. December 2022. |
30 |
Wellbutrin SR prescribing information. GlaxoSmithKline, LLC. December 2022. |
31 |
Wellbutrin XL prescribing information. Bausch Health Companies, Inc. March 2022. |
32 |
Halverson J, Beevers C, Kamholz B. Clinical Practice Review for Major Depressive Disorder. Anxiety and Depression Association of America, November 2020. https://adaa.org/resources-professionals/practice-guidelines-mdd. |
33 |
Kennedy SH, Lam RW, McIntyre RS, et. al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder. Canadian Journal Psychiatry. 2016, Vol. 61(9)540-560. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4994790/pdf/10.1177_0706743716659417.pdf |
34 |
Locke AB, Kirst N, Shuultz CG. Diagnosis and Management of Generalized Anxiety Disorder and Panic Disorder in Adults. Am Fam Physician. 2022;106(2):157-164. https://www.aafp.org/pubs/afp/issues/2022/0800/generalized-anxiety-disorder-panic-disorder.pdf. |
35 |
Fenske JN, Petersen K. Obsessive-Compulsive Disorder: Diagnosis and Management. Am Fam Physician. 2015 Nov 15;92(10):896-903. Available at: https://www.aafp.org/afp/2015/1115/p896.html |
36 |
Courtois CA, Sonis J, Brown LS, et. al. Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults(2017). American Psychological Association. Available at: https://www.apa.org/ptsd-guideline/ptsd.pdf |
37 |
van Amerigen M, Heimberg RG, Schneier F, et. al. Clinical Practice Review for Social Anxiety Disorder. Anxiety and Depression Association of America. September 15, 2015. Available at: https://adaa.org/resources-professionals/clinical-practice-review-social-anxiety |
38 |
Gilron I, Baron R, Jensen T. Neuropathic Pain: Principles of Diagnosis and Treatment. Mayo Clinic Proceedings, April 2015. Available at: https://www.mayoclinicproceedings.org/article/S0025-6196(15)00105-6/fulltext#sec6 |
39 |
Castelli, G., Desai, K., Cantone, R., Peripheral Neuropathy: Evaluation and Differential Diagnosis Treating Painful Diabetic Peripheral Neuropathy: An Update. American Family Physician. 2020;102(12):732-739. https://www.aafp.org/pubs/afp/issues/2020/1215/p732.html. |
40 |
Kia S, Choy E. Update on Treatment Guideline in Fibromyalgia Syndrome with Focus on Pharmacology. Biomedicines. 2017 Jun; 5(2): 20. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5489806/ |
41 |
American Society of Anesthesiologists, American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management. Anesthesiology. 2010;112:810-833. Available at: https://anesthesiology.pubs.asahq.org/article.aspx?articleid=1932775. |
POLICY AGENT SUMMARY STEP THERAPY
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Targeted MSC |
Available MSC |
Final Age Limit |
Preferred Status |
|
||||||
Aplenzin ; Forfivo xl ; Wellbutrin sr ; Wellbutrin xl |
Bupropion HCl Tab ER ; bupropion hbr tab er ; bupropion hcl tab ; bupropion hcl tab er |
100 MG ; 150 MG ; 174 MG ; 200 MG ; 300 MG ; 348 MG ; 450 MG ; 522 MG ; 75 MG |
M ; N ; O |
M ; N ; O ; Y |
|
|
Auvelity |
dextromethorphan hbr-bupropion hcl tab er |
45-105 MG |
M ; N ; O |
N |
|
|
Celexa |
citalopram hydrobromide cap ; citalopram hydrobromide oral soln ; citalopram hydrobromide tab |
10 MG ; 10 MG/5ML ; 20 MG ; 30 MG ; 40 MG |
M ; N ; O |
N ; O ; Y |
|
|
Cymbalta |
duloxetine hcl enteric coated pellets cap |
20 MG ; 30 MG ; 40 MG ; 60 MG |
M ; N ; O |
O ; Y |
|
|
Drizalma sprinkle |
duloxetine hcl cap delayed release sprinkle |
20 MG ; 30 MG ; 40 MG ; 60 MG |
M ; N ; O |
N |
|
|
Effexor xr |
venlafaxine besylate tab er ; venlafaxine hcl cap er ; venlafaxine hcl tab ; venlafaxine hcl tab er |
100 MG ; 112.5 MG ; 150 MG ; 225 MG ; 25 MG ; 37.5 MG ; 50 MG ; 75 MG |
M ; N ; O |
N ; O ; Y |
|
|
Fetzima ; Fetzima titration pack |
levomilnacipran hcl cap er |
120 MG ; 20 & 40 MG ; 20 MG ; 40 MG ; 80 MG |
M ; N ; O |
N |
|
|
Lexapro |
escitalopram oxalate soln ; escitalopram oxalate tab |
10 ; 10 MG ; 20 MG ; 5 MG ; 5 MG/5ML |
M ; N ; O |
O ; Y |
|
|
Paxil ; Paxil cr ; Pexeva |
paroxetine hcl oral susp ; paroxetine hcl tab ; paroxetine hcl tab er ; paroxetine mesylate tab |
10 MG ; 10 MG/5ML ; 12.5 MG ; 20 MG ; 25 MG ; 30 MG ; 37.5 MG ; 40 MG |
M ; N ; O |
N ; O ; Y |
|
|
Pristiq |
desvenlafaxine succinate tab er ; desvenlafaxine tab er |
100 MG ; 25 MG ; 50 MG |
M ; N ; O |
N ; O ; Y |
|
|
Prozac |
fluoxetine hcl cap ; fluoxetine hcl cap delayed release ; fluoxetine hcl solution ; fluoxetine hcl tab |
10 MG ; 20 MG ; 20 MG/5ML ; 40 MG ; 60 MG ; 90 MG |
M ; N ; O |
N ; O ; Y |
|
|
Remeron ; Remeron soltab |
mirtazapine orally disintegrating tab ; mirtazapine tab |
15 MG ; 30 MG ; 45 MG ; 7.5 MG |
M ; N ; O |
O ; Y |
|
|
Trintellix |
vortioxetine hbr tab |
10 MG ; 20 MG ; 5 MG |
M ; N ; O |
N |
|
|
Viibryd ; Viibryd starter pack |
vilazodone hcl tab ; vilazodone hcl tab starter kit |
10 & 20 MG ; 10 MG ; 20 MG ; 40 MG |
M ; N ; O |
N ; O ; Y |
|
|
Zoloft |
sertraline hcl cap ; sertraline hcl oral concentrate for solution ; sertraline hcl tab |
100 MG ; 150 MG ; 20 MG/ML ; 200 MG ; 25 MG ; 50 MG |
M ; N ; O |
N ; O ; Y |
|
|
POLICY AGENT SUMMARY QUANTITY LIMIT
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
QL Amount |
Dose Form |
Day Supply |
Duration |
Addtl QL Info |
Allowed Exceptions |
Targeted NDCs When Exclusions Exist |
|
|||||||||
|
Bupropion HCl Tab 100 MG |
100 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
|
Bupropion HCl Tab 75 MG |
75 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
citalopram hydrobromide cap |
30 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|
citalopram hydrobromide oral soln |
10 MG/5ML |
600 |
mLs |
30 |
DAYS |
|
|
|
|
desvenlafaxine tab er |
100 MG ; 50 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Duloxetine HCl Enteric Coated Pellets Cap 40 MG (Base Eq) |
40 MG |
90 |
Capsules |
30 |
DAYS |
|
|
|
|
escitalopram oxalate soln |
5 MG/5ML |
600 |
mLs |
30 |
DAYS |
|
|
|
|
fluoxetine hcl cap delayed release |
90 MG |
4 |
Capsules |
28 |
DAYS |
|
|
|
|
fluoxetine hcl solution |
20 MG/5ML |
600 |
mLs |
30 |
DAYS |
|
|
|
|
Fluoxetine HCl Tab 10 MG |
10 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Fluoxetine HCl Tab 20 MG |
20 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
|
Fluoxetine HCl Tab 60 MG |
60 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
fluvoxamine maleate cap er |
100 MG ; 150 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
|
Fluvoxamine Maleate Tab 100 MG |
100 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
|
Fluvoxamine Maleate Tab 25 MG |
25 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Fluvoxamine Maleate Tab 50 MG |
50 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
sertraline hcl cap |
150 MG ; 200 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|
venlafaxine besylate tab er |
112.5 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
venlafaxine hcl tab |
100 MG ; 25 MG ; 37.5 MG ; 50 MG ; 75 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
|
Venlafaxine HCl Tab ER 24HR 150 MG (Base Equivalent) |
150 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Venlafaxine HCl Tab ER 24HR 225 MG (Base Equivalent) |
225 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Venlafaxine HCl Tab ER 24HR 37.5 MG (Base Equivalent) |
37.5 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Venlafaxine HCl Tab ER 24HR 75 MG (Base Equivalent) |
75 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
Aplenzin |
bupropion hbr tab er |
174 MG ; 348 MG ; 522 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Auvelity |
dextromethorphan hbr-bupropion hcl tab er |
45-105 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Celexa |
citalopram hydrobromide tab |
10 MG ; 20 MG ; 40 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Cymbalta |
Duloxetine HCl Enteric Coated Pellets Cap 20 MG (Base Eq) |
20 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
Cymbalta |
Duloxetine HCl Enteric Coated Pellets Cap 30 MG (Base Eq) |
30 MG |
60 |
Capsules |
30 |
DAYS |
Smart QL: 2 capsules daily for 60 days 3 capsules daily thereafter |
|
|
Cymbalta |
Duloxetine HCl Enteric Coated Pellets Cap 60 MG (Base Eq) |
60 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
Drizalma sprinkle |
duloxetine hcl cap delayed release sprinkle |
20 MG ; 30 MG ; 40 MG ; 60 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
Effexor xr |
Venlafaxine HCl Cap ER 24HR 150 MG (Base Equivalent) |
150 MG |
30 |
Capsules |
30 |
DAYS |
Smart QL: 1 capsule daily for 60 days 2 capsules daily thereafter |
|
|
Effexor xr |
Venlafaxine HCl Cap ER 24HR 37.5 MG (Base Equivalent) |
37.5 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Effexor xr |
Venlafaxine HCl Cap ER 24HR 75 MG (Base Equivalent) |
75 MG |
90 |
Capsules |
30 |
DAYS |
|
|
|
Fetzima |
levomilnacipran hcl cap er |
120 MG ; 20 MG ; 40 MG ; 80 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Fetzima titration pack |
levomilnacipran hcl cap er |
20 & 40 MG |
28 |
Capsules |
180 |
DAYS |
|
|
|
Forfivo xl ; Wellbutrin xl |
bupropion hcl tab er |
150 MG ; 300 MG ; 450 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Lexapro |
Escitalopram Oxalate Tab 10 MG (Base Equiv) |
10 ; 10 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Lexapro |
Escitalopram Oxalate Tab 20 MG (Base Equiv) |
20 MG |
30 |
Tablets |
30 |
DAYS |
Smart QL: 1 tablet daily for 60 days 2 tablets daily thereafter |
|
|
Lexapro |
Escitalopram Oxalate Tab 5 MG (Base Equiv) |
5 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Paxil |
Paroxetine HCl Oral Susp 10 MG/5ML (Base Equiv) |
10 MG/5ML |
900 |
mLs |
30 |
DAYS |
|
|
|
Paxil |
Paroxetine HCl Tab 10 MG |
10 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Paxil |
Paroxetine HCl Tab 20 MG |
20 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Paxil |
Paroxetine HCl Tab 30 MG |
30 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Paxil |
Paroxetine HCl Tab 40 MG |
40 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Paxil cr |
Paroxetine HCl Tab ER 24HR 12.5 MG |
12.5 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Paxil cr |
Paroxetine HCl Tab ER 24HR 25 MG |
25 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Paxil cr |
Paroxetine HCl Tab ER 24HR 37.5 MG |
37.5 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Pexeva |
Paroxetine Mesylate Tab 10 MG (Base Equiv) |
10 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Pexeva |
Paroxetine Mesylate Tab 20 MG (Base Equiv) |
20 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Pexeva |
Paroxetine Mesylate Tab 30 MG (Base Equiv) |
30 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Pexeva |
Paroxetine Mesylate Tab 40 MG (Base Equiv) |
40 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Pristiq |
desvenlafaxine succinate tab er |
100 MG ; 25 MG ; 50 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Prozac |
Fluoxetine HCl Cap 10 MG |
10 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Prozac |
Fluoxetine HCl Cap 20 MG |
20 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
Prozac |
Fluoxetine HCl Cap 40 MG |
40 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
Remeron |
mirtazapine tab |
15 MG ; 30 MG ; 45 MG ; 7.5 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Remeron soltab |
mirtazapine orally disintegrating tab |
15 MG ; 30 MG ; 45 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Trintellix |
vortioxetine hbr tab |
10 MG ; 20 MG ; 5 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Viibryd |
vilazodone hcl tab |
10 MG ; 20 MG ; 40 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Viibryd starter pack |
vilazodone hcl tab starter kit |
10 & 20 MG |
1 |
Tablets |
180 |
DAYS |
|
|
|
Wellbutrin sr |
Bupropion HCl Tab ER ; bupropion hcl tab er |
100 MG ; 150 MG ; 200 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Zoloft |
Sertraline HCl Oral Concentrate for Solution 20 MG/ML |
20 MG/ML |
300 |
mLs |
30 |
DAYS |
|
|
|
Zoloft |
Sertraline HCl Tab 100 MG |
100 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Zoloft |
Sertraline HCl Tab 25 MG |
25 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Zoloft |
Sertraline HCl Tab 50 MG |
50 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Zurzuvae |
zuranolone cap |
20 MG |
28 |
Capsules |
365 |
DAYS |
*Quantity limit is cumulative for the 20mg and 25 mg strengths. |
|
|
Zurzuvae |
zuranolone cap |
25 MG |
28 |
Capsules |
365 |
DAYS |
*Quantity limit is cumulative for the 20mg and 25 mg strengths. |
|
|
Zurzuvae |
zuranolone cap |
30 MG |
14 |
Capsules |
365 |
DAYS |
|
|
|
ADDITIONAL QUANTITY LIMIT INFORMATION
Wildcard |
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Additional QL Information |
Targeted NDCs When Exclusions Exist |
Effective Date |
Term Date |
|
|||||||
58180025106730 |
Cymbalta |
Duloxetine HCl Enteric Coated Pellets Cap 30 MG (Base Eq) |
30 MG |
Smart QL: 2 capsules daily for 60 days 3 capsules daily thereafter |
|
|
|
58180090107050 |
Effexor xr |
Venlafaxine HCl Cap ER 24HR 150 MG (Base Equivalent) |
150 MG |
Smart QL: 1 capsule daily for 60 days 2 capsules daily thereafter |
|
|
|
58160034100330 |
Lexapro |
Escitalopram Oxalate Tab 20 MG (Base Equiv) |
20 MG |
Smart QL: 1 tablet daily for 60 days 2 tablets daily thereafter |
|
|
|
58060090000120 |
Zurzuvae |
zuranolone cap |
20 MG |
*Quantity limit is cumulative for the 20mg and 25 mg strengths. |
|
|
|
58060090000125 |
Zurzuvae |
zuranolone cap |
25 MG |
*Quantity limit is cumulative for the 20mg and 25 mg strengths. |
|
|
|
CLIENT SUMMARY – STEP THERAPY
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
Aplenzin ; Forfivo xl ; Wellbutrin sr ; Wellbutrin xl |
Bupropion HCl Tab ER ; bupropion hbr tab er ; bupropion hcl tab ; bupropion hcl tab er |
100 MG ; 150 MG ; 174 MG ; 200 MG ; 300 MG ; 348 MG ; 450 MG ; 522 MG ; 75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Auvelity |
dextromethorphan hbr-bupropion hcl tab er |
45-105 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Celexa |
citalopram hydrobromide cap ; citalopram hydrobromide oral soln ; citalopram hydrobromide tab |
10 MG ; 10 MG/5ML ; 20 MG ; 30 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Cymbalta |
duloxetine hcl enteric coated pellets cap |
20 MG ; 30 MG ; 40 MG ; 60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Drizalma sprinkle |
duloxetine hcl cap delayed release sprinkle |
20 MG ; 30 MG ; 40 MG ; 60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Effexor xr |
venlafaxine besylate tab er ; venlafaxine hcl cap er ; venlafaxine hcl tab ; venlafaxine hcl tab er |
100 MG ; 112.5 MG ; 150 MG ; 225 MG ; 25 MG ; 37.5 MG ; 50 MG ; 75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Fetzima ; Fetzima titration pack |
levomilnacipran hcl cap er |
120 MG ; 20 & 40 MG ; 20 MG ; 40 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lexapro |
escitalopram oxalate soln ; escitalopram oxalate tab |
10 ; 10 MG ; 20 MG ; 5 MG ; 5 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Paxil ; Paxil cr ; Pexeva |
paroxetine hcl oral susp ; paroxetine hcl tab ; paroxetine hcl tab er ; paroxetine mesylate tab |
10 MG ; 10 MG/5ML ; 12.5 MG ; 20 MG ; 25 MG ; 30 MG ; 37.5 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Pristiq |
desvenlafaxine succinate tab er ; desvenlafaxine tab er |
100 MG ; 25 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Prozac |
fluoxetine hcl cap ; fluoxetine hcl cap delayed release ; fluoxetine hcl solution ; fluoxetine hcl tab |
10 MG ; 20 MG ; 20 MG/5ML ; 40 MG ; 60 MG ; 90 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Remeron ; Remeron soltab |
mirtazapine orally disintegrating tab ; mirtazapine tab |
15 MG ; 30 MG ; 45 MG ; 7.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Trintellix |
vortioxetine hbr tab |
10 MG ; 20 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Viibryd ; Viibryd starter pack |
vilazodone hcl tab ; vilazodone hcl tab starter kit |
10 & 20 MG ; 10 MG ; 20 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zoloft |
sertraline hcl cap ; sertraline hcl oral concentrate for solution ; sertraline hcl tab |
100 MG ; 150 MG ; 20 MG/ML ; 200 MG ; 25 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
CLIENT SUMMARY – QUANTITY LIMITS
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
|
Bupropion HCl Tab 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Bupropion HCl Tab 75 MG |
75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
citalopram hydrobromide cap |
30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
citalopram hydrobromide oral soln |
10 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
desvenlafaxine tab er |
100 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Duloxetine HCl Enteric Coated Pellets Cap 40 MG (Base Eq) |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
escitalopram oxalate soln |
5 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
fluoxetine hcl cap delayed release |
90 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
fluoxetine hcl solution |
20 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Fluoxetine HCl Tab 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Fluoxetine HCl Tab 20 MG |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Fluoxetine HCl Tab 60 MG |
60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
fluvoxamine maleate cap er |
100 MG ; 150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Fluvoxamine Maleate Tab 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Fluvoxamine Maleate Tab 25 MG |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Fluvoxamine Maleate Tab 50 MG |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
sertraline hcl cap |
150 MG ; 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
venlafaxine besylate tab er |
112.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
venlafaxine hcl tab |
100 MG ; 25 MG ; 37.5 MG ; 50 MG ; 75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Venlafaxine HCl Tab ER 24HR 150 MG (Base Equivalent) |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Venlafaxine HCl Tab ER 24HR 225 MG (Base Equivalent) |
225 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Venlafaxine HCl Tab ER 24HR 37.5 MG (Base Equivalent) |
37.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Venlafaxine HCl Tab ER 24HR 75 MG (Base Equivalent) |
75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Aplenzin |
bupropion hbr tab er |
174 MG ; 348 MG ; 522 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Auvelity |
dextromethorphan hbr-bupropion hcl tab er |
45-105 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Celexa |
citalopram hydrobromide tab |
10 MG ; 20 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Cymbalta |
Duloxetine HCl Enteric Coated Pellets Cap 20 MG (Base Eq) |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Cymbalta |
Duloxetine HCl Enteric Coated Pellets Cap 30 MG (Base Eq) |
30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Cymbalta |
Duloxetine HCl Enteric Coated Pellets Cap 60 MG (Base Eq) |
60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Drizalma sprinkle |
duloxetine hcl cap delayed release sprinkle |
20 MG ; 30 MG ; 40 MG ; 60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Effexor xr |
Venlafaxine HCl Cap ER 24HR 150 MG (Base Equivalent) |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Effexor xr |
Venlafaxine HCl Cap ER 24HR 37.5 MG (Base Equivalent) |
37.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Effexor xr |
Venlafaxine HCl Cap ER 24HR 75 MG (Base Equivalent) |
75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Fetzima |
levomilnacipran hcl cap er |
120 MG ; 20 MG ; 40 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Fetzima titration pack |
levomilnacipran hcl cap er |
20 & 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Forfivo xl ; Wellbutrin xl |
bupropion hcl tab er |
150 MG ; 300 MG ; 450 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lexapro |
Escitalopram Oxalate Tab 10 MG (Base Equiv) |
10 ; 10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lexapro |
Escitalopram Oxalate Tab 20 MG (Base Equiv) |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lexapro |
Escitalopram Oxalate Tab 5 MG (Base Equiv) |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Paxil |
Paroxetine HCl Oral Susp 10 MG/5ML (Base Equiv) |
10 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Paxil |
Paroxetine HCl Tab 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Paxil |
Paroxetine HCl Tab 20 MG |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Paxil |
Paroxetine HCl Tab 30 MG |
30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Paxil |
Paroxetine HCl Tab 40 MG |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Paxil cr |
Paroxetine HCl Tab ER 24HR 12.5 MG |
12.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Paxil cr |
Paroxetine HCl Tab ER 24HR 25 MG |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Paxil cr |
Paroxetine HCl Tab ER 24HR 37.5 MG |
37.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Pexeva |
Paroxetine Mesylate Tab 10 MG (Base Equiv) |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Pexeva |
Paroxetine Mesylate Tab 20 MG (Base Equiv) |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Pexeva |
Paroxetine Mesylate Tab 30 MG (Base Equiv) |
30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Pexeva |
Paroxetine Mesylate Tab 40 MG (Base Equiv) |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Pristiq |
desvenlafaxine succinate tab er |
100 MG ; 25 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Prozac |
Fluoxetine HCl Cap 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Prozac |
Fluoxetine HCl Cap 20 MG |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Prozac |
Fluoxetine HCl Cap 40 MG |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Remeron |
mirtazapine tab |
15 MG ; 30 MG ; 45 MG ; 7.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Remeron soltab |
mirtazapine orally disintegrating tab |
15 MG ; 30 MG ; 45 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Trintellix |
vortioxetine hbr tab |
10 MG ; 20 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Viibryd |
vilazodone hcl tab |
10 MG ; 20 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Viibryd starter pack |
vilazodone hcl tab starter kit |
10 & 20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Wellbutrin sr |
Bupropion HCl Tab ER ; bupropion hcl tab er |
100 MG ; 150 MG ; 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zoloft |
Sertraline HCl Oral Concentrate for Solution 20 MG/ML |
20 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zoloft |
Sertraline HCl Tab 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zoloft |
Sertraline HCl Tab 25 MG |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zoloft |
Sertraline HCl Tab 50 MG |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zurzuvae |
zuranolone cap |
30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zurzuvae |
zuranolone cap |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zurzuvae |
zuranolone cap |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
STEP THERAPY CLINICAL CRITERIA FOR APPROVAL
Module |
Clinical Criteria for Approval |
Brand Agents other than Cymbalta/Drizalma |
TARGET AGENT(S) Aplenzin (bupropion) Auvelity (dextromethorphan hbr-bupropion hcl tab er) Celexa (citalopram)* Citalopram (capsules)^ Desvenlafaxine ER (tablets)^ Effexor (venlafaxine)* Effexor XR (venlafaxine extended release)* Fetzima (levomilnacipran extended release) Fluoxetine 60 mg (tablets)*^ Fluoxetine delayed release (capsules)^ Forfivo XL (bupropion extended release) Lexapro (escitalopram)* Paxil (paroxetine hydrochloride)* Paxil CR (paroxetine extended release)* Pexeva (paroxetine mesylate) Pristiq (desvenlafaxine succinate)* Prozac (fluoxetine)* Remeron (mirtazapine)* Remeron SolTab (mirtazapine)* Sertraline (capsules)^ Trintellix (vortioxetine) Viibryd (vilazodone)* Wellbutrin (bupropion)* Wellbutrin SR (bupropion extended release)* Wellbutrin XL (bupropion extended release)* Zoloft (sertraline)* * - available as a generic; generic included as a prerequisite in step therapy program ^ – branded generic product(s) available; targeted in the step therapy program
Brand Antidepressant Agent(s) (except Cymbalta and Drizalma) will be approved when ONE of the following are met:
Length of Approval: 12 months NOTE: If Quantity Limit applies, please refer to Quantity Limit Criteria. |
Cymbalta and Drizalma |
TARGET AGENT(S) Cymbalta (duloxetine)* * - available as a generic; generic included as a prerequisite in step therapy program Cymbalta and Drizalma will be approved when ONE of the following are met:
Length of Approval: 12 months NOTE: If Quantity Limit applies, please refer to Quantity Limit Criteria. |
QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL
Module |
Clinical Criteria for Approval |
|
Quantity limit for the Target Agent(s) will be approved when ONE of the following is met:
Length of Approval: up to 12 months
|
This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.
Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.
Commercial _ PS _ Antidepressant_Agents_STQL _ProgSum_ 10-01-2024